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8.4 Insufficient breastmilk

Perceived breastmilk insufficiency

Along with nipple pain, this is the most common breastfeeding problem which women experience and a reason mothers give for introducing artificial infant formula and weaning prematurely. "Not enough milk" is reported by women, but usually their perception does not match reality.1,2

Education about normal infant behavior, normal infant breastfeeding frequency, good latch and normal infant output will prevent this misunderstanding and unfortunate outcome.

Output is the most obvious and reassuring way for a mother to know her baby is being well fed. Remind the mother: If it's coming out, it must have gone in!

How is breastmilk production regulated?

You will recall

Secretory differentiation (Lactogenesis I)
  • commences during pregnancy
  • regulates production of colostrum
  • is an endocrine function dependent on hormonal control
Secretory activation (Lactogenesis II)
  • commences soon after birthing, when serum prolactin is high and progesterone is suddenly removed
  • is seen clinically as a copious production of breastmilk
  • is an endocrine function

Lactogenesis III

Lactogenesis III is the maintenance of milk synthesis .

This is an autocrine function, meaning the control is under local control at the breast. Simply explained, milk must be removed from the breast for more milk to be made. Each breast is independent of the other in regards to milk production.

Researchers have described the following mechanisms, which both work together.

  1. Feedback Inhibitor of Lactation (FIL)

    FIL is a small whey protein that is found in breastmilk. It works on an inhibitory basis. The more milk present in the breast, the more FIL is present to be absorbed and exert its inhibitory effect on milk production. Conversely, as the breastmilk volume in the breast drops there is less inhibitory protein and production of breastmilk is more rapid.

  2. Prolactin receptors:

    Prolactin is necessary to form the substrate of breastmilk, therefore the amount of prolactin in the milk is more important to milk production than serum (blood) prolactin. Prolactin must pass from the bloodstream through the alveolus and into the milk.
    Prolactin receptors on the alveolus control how much prolactin can move into the milk. (Imagine the prolactin receptors to be like keyholes, and prolactin is the key. The keyhole must be the perfect shape to allow the key to fit into it.) As the alveoli become increasingly distended, such as occurs as the breast is filling, less prolactin is found in the alveolus so milk production slows.3 As the alveolus empties of milk, the cells flatten allowing prolactin to bind to the receptors, pass through them and into the milk increasing the rate of milk production again.4 5

What was that again?

Simply put:

full breast = lots of milk in alveoli = lots of FIL = slow breastmilk production

full breast = distorted receptors = slow passage of prolactin = slow breastmilk production

Two very good reasons to ensure frequent, effective milk removal for adequate milk production.

Workbook Activity 8.8

Complete Activity 8.8 in your workbook.

Breast storage capacity and rate of breastmilk production

Breastmilk storage capacity is unique to each mother, and each breast.

  • A mother who has a small storage capacity will find that her baby feeds frequently, removing most milk at each breastfeed. This mother's rate of breastmilk production will be high most of the time. It would be inappropriate to suggest that her baby should be feeding less frequently, or expect him to sleep through the night, as this is most likely to result in failure to thrive and an insufficient milk supply.
  • A mother with a large storage capacity will have higher degree of breast fullness for longer. Her infant made need only one breast per feed or may feed less frequently. Breastmilk production during this time will be slow, increasing as the available milk is removed.

Over a 24-hour period both babies may take very similar amounts of milk, but one baby may have to breastfeed many more times per day to achieve it.

Insufficient breastmilk

Diagnosis

Diagnosis of insufficient breastmilk supply is generally made by observing the condition of the baby. As mentioned in Topic 7.2 , it may not be low supply that has caused failure to thrive, which is why a pediatric review is always indicated.

Your thorough history-taking and excellent assessment and observational skills may reveal the reason for insufficient milk. These can be summarised as:

Maternal:

  • medical conditions such as polycystic ovary syndrome, retained placenta, obesity, diabetes, large blood loss
  • breast conditions - surgery (reduction mammoplasty, augmentation), hypoplasia
  • other - contraceptive pill, subsequent pregnancy

Infant:

any medical condition or temporary circumstance which prevents adequate sucking strength and drainage of the breast.

Delayed onset

The absence of noticeable fullness/heaviness of the breasts within 72 hours is considered delayed onset of lactogenesis.6

The infant's needs are increasing daily, so without adequate milk volume, the infant is at risk of dehydration, weight loss, hyperbilirubinemia, loss of energy and breast refusal.

Refer back to your notes about the biochemical changes which occur after birth to initiate secretory activation. Progesterone drops, prolactin remains high, lactose increases in colostrum. Insulin, thyroxine and glucocorticoids are also involved, but the role is uncertain.
Medical conditions which impair any of the chemical and hormonal changes are associated with delay of secretory activation. Your further study in Topic 8.5 will assist your further understanding of the potential impact on delayed onset of secretory activation.

Being proactive

What measures will you take when you are caring for a mother-to-be/new mother who falls into one of these risk categories?

How can you help to reduce the impact of her risk on delayed secretory activation?

Management

A team approach may be required depending on the cause. Insufficient milk may be temporary of permanent, however, your role will be to guide the mother and assist her to effectively and regularly remove breastmilk to encourage rapid breastmilk production.

  1. The breastfeed - be a detective, examine the infant and assess a breastfeed as discussed in Topic 5.3

    • Observe for good positioning, deep latch, effective suckling, swallowing. Believe it or not this very first step is one often neglected, particularly by health professionals whose specialty is not breastfeeding.
    • Correcting a poor latch may be all that's required to solve the mother's lactation insufficiency.
    • Breast compression during breastfeeding increases milk transfer. Breast compression involves holding the breast in the hand and gently squeezing it. Hold the compression until the baby's sucking pattern changes then release. Repeat.
    • Switch feeding can also be effective. When the infant stops nutritive sucking on the first breast, swap to the other breast. Repeat this on each breast to encourage infant's interest and promote milk synthesis.
    • Use a tube-feeding device at the breast for supplements. If possible commence the breastfeed without the supplement flowing to encourage good drainage of the breast first. When nutritive sucking stops allow the supplemental milk to flow. Review Topic 7.5.1
  2. Breastfeeding frequency

    • Unfortunately many mothers are told they must feed 'X' number of times per day for 'X' number of minutes. They believe that long gaps between the feeds are a sign of a good baby and that frequent feeding will spoil the baby or create 'bad' habits, etc.
    • Educate the mother about milk synthesis and breast storage capacity so that she can feel confident about the optimal breastfeeding practices to promote her milk supply.
    • Frequent and effective breastmilk removal from the breast at each feed, by a well-latched baby or breast expression, will produce more milk in each breast.
  3. Additional stimulation - milk removal between breastfeeds

    • Fact: The more frequently milk is removed from the breast the more rapidly the breast will produce breastmilk. The fuller the breast, the slower the breast will make breastmilk.
    • Additional milk removal between breastfeeds will increase total breastmilk produced in that period. Use this milk as a supplement later.
    • Express immediately after breastfeeding IF the baby does not remove all breastmilk from the breast each breastfeed, as may happen in the mornings when volume contained in the breast is greater, or the baby has an ineffectual suck. (And pump again in another hour)
  4. Galactagogues - discuss the pros/cons and types available

    • A galactagogue is a substance that increases the volume of breastmilk produced.
    • Effective galactagogues include domperidone and metoclopramide, as well as the herbals fenugreek, blessed thistle and goat rue.
    • Galactogogues will only be successful if combined with clinical measures that ensure frequent, effective milk removal.
  5. Counselling the mother - sensitivity and caring will be needed to assist this mother.

    • Reassure her that your recommendations won't be detrimental to the baby (and make sure they aren't - ensure the baby receives adequate nutrition, which may include artificial infant formula.) .
    • Educate the mother about how milk production is controlled in her breast. This knowledge can be very empowering, particularly if mother had been limiting feeds based on erroneous advice.
    • Be sensitive to her feelings; some people have probably criticised her decision to breastfeed, and she may see this problem as justification of their criticism.
    • Be careful that she doesn't perceive you to be unapproachable if she does decide to artificially feed. She's still going to need lots of support to help her through possible emotional and guilt reactions.

When is the best time to express?

Assume a mother has an insufficient milk supply. Her baby latches effectively and drains both breasts well each breastfeed. When will you tell her to pump?

Immediately after breastfeeding?? This is what is frequently advised. Mother breastfeeds, then pumps and gets only a few mls, or maybe nothing. That's understandable: the baby had just breastfed effectively. Mother feels disheartened - it proves her inability to provide for her baby. Breastmilk production will not be enhanced because the breast was already as empty as possible.

However, if she waits for an hour then pumps, breastmilk production would have been at maximum for the majority of that time, beginning to slow now as more milk accumulates in the breast. Pumping may produce 30ml (1 ounce) from each breast (depends on individual rate of milk production). The breast will be emptied again, milk production will be back to maximum rate once again enhancing overall volume produced, and the mother will feel positive about her ability to produce breastmilk.

This is an example of applying your knowledge of physiology to a problem.

Workbook Activity 8.9

Complete Activity 8.9 in your workbook.

Did you know?

Women are able to relactate having prematurely weaned their baby, and also induce lactation, if they did not previously go through pregnancy. Always offer this as an option for mothers who weaned prematurely or are adopting a baby.

What should I remember?

  • That lactogenesis III is the maintenance of milk secretion.
  • The more breastmilk removed from the breast the more rapidly more breastmilk will be made.
  • Be able to describe the 2 mechanisms of autocrine control of milk synthesis at the breast level.
  • Understand how milk storage capacity impacts on breastfeeding frequency.
  • How to maximise a mother's ability to produce an adequate milk supply.

Self-test quiz

Notes

  1. # Amir LH (2006) Breastfeeding--managing supply difficulties.
  2. # Lamontagne C et al. (2008) The breastfeeding experience of women with major difficulties who use the services of a breastfeeding clinic: a descriptive study.
  3. # Cregan MD et al. (2002, March) Milk prolactin, feed volume and duration between feeds in women breastfeeding their full-term infants over a 24 h period
  4. # DeCarvalho MD (1983) Effect of frequent breastfeeding on early milk production and infant weight gain
  5. # Zappa AA (1988) Relationship between maternal parity, basal prolactin levels and neonatal breast milk intake
  6. # Nommsen-Rivers LA et al. (2010) Delayed onset of lactogenesis among first-time mothers is related to maternal obesity and factors associated with ineffective breastfeeding.